Deepanshu Jain

Obesity and Cecal Intubation Time

Background/Aims: Obesity is a much-debated factor with conflicting evidence regarding its association with cecum intubation rates during colonoscopy. We aimed to identify the association between cecal intubation (CI) time and obesity by eliminating confounding factors. Methods: A retrospective chart review of subjects undergoing outpatient colonoscopy was conducted. The population was categorized by sex and obesity (body mass index [BMI, kg/m2]: I, <24.9; II, 25 to 29.9; III, ≥30). CI time was used as a marker for a difficult colonoscopy. Mean CI times (MCT) were compared for statistical significance using analysis of variance tests. Results: A total of 926 subjects were included. Overall MCT was 15.7±7.9 minutes, and it was 15.9±7.9 and 15.5±7.9 minutes for men and women, respectively. MCT among women for BMI category I, II, and III was 14.4±6.5, 15.5±8.3, and 16.2±8.1 minutes (p=0.55), whereas for men, it was 16.3±8.9, 15.9±8.0, and 15.6±7.2 minutes (p=0.95), respectively. Conclusions: BMI had a positive association with CI time for women, but had a negative association with CI for men.

Esophageal Stricture Prevention after Endoscopic Submucosal Dissection

Advances in diagnostic modalities and improvement in surveillance programs for Barrett esophagus has resulted in an increase in the incidence of superficial esophageal cancers (SECs). SEC, due to their limited metastatic potential, are amenable to non-invasive treatment modalities. Endoscopic ultrasound, endoscopic mucosal resection, and endoscopic submucosal dissection (ESD) are some of the new modalities that gastroenterologists have used over the last decade to diagnose and treat SEC. However, esophageal stricture (ES) is a very common complication and a major cause of morbidity post-ESD. In the past few years, there has been a tremendous effort to reduce the incidence of ES among patients undergoing ESD. Steroids have shown the most consistent results over time with minimal complications although the preferred mode of delivery is debatable, with both systemic and local therapy having pros and cons for specific subgroups of patients. Newer modalities such as esophageal stents, autologous cell sheet transplantation, polyglycolic acid, and tranilast have shown promising results but the depth of experience with these methods is still limited. We have summarized case reports, prospective single center studies, and randomized controlled trials describing the various methods intended to reduce the incidence of ES after ESD. Indications, techniques, outcomes, limitations, and reported complications are discussed.

Endoscopic Bypass Using Endobarrier Devices: Efficacy in Treating Obesity and Metabolic Syndrome.

Obesity is a rapidly growing pandemic. Scope of pharmacotherapy and bariatric surgery in managing obesity is ever rising. The role of minimally invasive techniques to achieve preoperative weight loss and improve postbariatric surgery outcomes is an area of new interest. The initial experience with endobarrier devices in achieving weight loss among obese subjects has shown promising results. In addition, the impact of these interventions on comorbidities commonly associated with obesity like diabetes mellitus type 2 and hyperlipidemia has further expanded their potential for use in future. In this review article, we have summarized case report, prospective single and multicenter studies, and randomized-controlled trials describing the use of endobarrier devices. Indications, techniques, outcomes, limitations, and complications reported are discussed.

Submucosal tunneling endoscopic resection of upper gastrointestinal tract tumors arising from muscularis propria

The management of incidentally discovered small upper gastrointestinal (GI) tract submucosal tumors (SMT) remains debatable. In this review, we summarize the evolving experience with submucosal tunneling endoscopic resection (STER) of upper GI SMTs originating from the muscularis propria. From 16 original studies, we reviewed a total of 703 patients with 736 lesions. Of these, 436 were located in the esophagus, 146 in the esophagogastric junction (EGJ) and 154 in the stomach. The composite complete resection rate (CRR) for STER of upper GI tumors arising from the muscularis propria layer was 99.8% (445/446). The composite CRR for STER of esophageal, EGJ and gastric SMTs arising from the muscularis propria layer was 100% (208/208),100% (78/78)and 100% (115/115), respectively. The composite en bloc resection rate (EBRR) for STER of upper GI tumors arising from the muscularis propria layer was 94.6% (679/718). The composite EBRR for STER of esophageal, EGJ and gastric SMTs arising from the muscularis propria layer was 98.6% (205/208), 96.2% (75/78) and 97.9% (95/97), respectively. Tumor recurrence rate was 0%. The reported complication rate for STER was high but the majority responded to conservative management. STER is a minimally invasive and efficacious alternative to surgery, especially for patients with small tumors (<3 cm). Careful selection of candidates remains crucial for excluding potentially malignant tumors.

Endoscopic full thickness resection for gastric tumors originating from muscularis propria

AIM To do systematic review of current literature for endoscopic full thickness resection (EFTR) technique for gastric tumors originating from muscularis propria. METHODS An extensive English literature search was done till December 2015; using PubMed and Google scholar to identify the peer reviewed original and review articles using keywords-EFTR, gastric tumor, muscularis propria. Human only studies were included. The references of pertinent studies were manually searched to identify additional relevant studies. The indications, procedural details, success rates, clinical outcomes, complications and limitations were considered. For the purpose of review, data from individual studies was combined to calculate mean. No other statistical test was applied. RESULTS A total of 9 original articles were identified. Four articles were from same institute and the time frames of these studies were overlapping. To avoid duplication of data, only the study with patients over the longest time interval was included and other three were excluded. In total six studies were included in the final review. In our systematic review, the mean success rate for EFTR of gastric tumors originating from muscularis propria was 96.8%. The mean procedure time varied from a minimum of 37 min to a maximum of 105 min. There was no reported mortality from the technique itself. The most common histological diagnosis was gastrointestinal stromal tumors and leiomyoma. Gastric wall defect closure by either metallic clips or over the scope clip (OTSC) had similar outcomes although experience with OTSC was limited to smaller lesions (< 3 cm). CONCLUSION EFTR is a minimally invasive technique to resect gastric submucosal tumors originating from muscularis propria with a high success rate and low complication rate.

Transoral Incisionless Fundoplication for Refractory Gastroesophageal Reflux Disease: Where Do We Stand?

Gastroesophageal reflux disease (GERD) is a chronic, progressive, and costly medical condition affecting a substantial proportion of the world population, predominantly the Western population. The available treatment options for patients with refractory GERD symptoms are limited to either laparoscopic surgery with significant sequelae or potentially lifelong, high-dose proton pump inhibitor therapy. The restoration of the antireflux competence of the gastroesophageal junction at the anatomic and physiologic levels is critical for the effective long-term treatment of GERD. Transoral incisionless fundoplication (TIF) surgery is a safe, well-tolerated, and effective treatment that has yielded significant symptomatic improvement in patients with medically refractory GERD symptoms. In this review article, we have summarized case series and reports describing the role of TIF for patients with gastroesophageal reflux symptoms. The reported indications, techniques, complications, and success rates are also discussed.

Predicting Colonoscopy Time: A Quality Improvement Initiative

Background/Aims There is lack of consensus on the optimal time allotted for colonoscopy, which increases patient wait times. Our aim was to identify and quantify the individual pre-procedural factors that determine the total procedure time (TPT) of colonoscopy. Methods This retrospective study involved 4,494 subjects, undergoing outpatient colonoscopy. Effects of age, sex, body mass index, abdominal surgery history, procedure indication (screening, surveillance, or diagnostic), procedure session (morning or afternoon), and endoscopist’s experience (fellow or attending) on TPT were evaluated using multiple regression analysis. A p<0.05 was considered significant. Results A total of 1,239 subjects satisfied the inclusion/exclusion criteria. Women, older individuals, and those with a history of abdominal surgery were found to have a shorter TPT (p>0.05) as did afternoon session colonoscopies (p=0.004). Less experienced endoscopists had longer TPTs (p>0.05). Screening (p=0.01) and surveillance (p=0.008) colonoscopies had a longer TPT than diagnostic procedures. Overall, the F-value of the regression model was 0.0009. Conclusions The indication for colonoscopy and the time of day have statistically significant associations with TPT. These results will help in streamlining workflow, reduce wait time, and improve patient satisfaction.

Endoscopic Sleeve Gastroplasty - A New Tool to Manage Obesity

Obesity is a growing pandemic across the world. Dietary restrictions and behavior modifications alone have a limited benefit. Bariatric surgery, despite being the current gold standard, has limited acceptance by patients due to cost and associated morbidity. In our review, we have discussed nine original studies describing endoscopic sleeve gastroplasty (ESG). A total of 172 subjects successfully underwent ESG. Of 65 subjects with follow up data, 95.4% (62/65) had intact gastric sleeve confirmed via esophagogastroduodenoscopy or oral contrast study at the end of study specific follow up interval (the longest being 6 months). Individual studies reported a technical success rate for intact gastric sleeve from as low as 50% to as high as 100%. A statistically significant p<0.05) weight loss was reported in seven of the eight studies with available data. None of the patients experienced any intra-procedure complications, and approximately 2.3% (4/172) of patients experienced major post-procedure complications; however, no mortality was reported. Majority of the studies reported relatively high incidence of minor post-procedure complications, which improved with symptomatic treatment alone. Good patient tolerance with comparable clinical efficacy in achieving and sustaining desired weight loss makes ESG an attractive option to consider among other bariatric therapies.

Importance of reporting segmental bowel preparation scores during colonoscopy in clinical practice

AIM To evaluate the impact of reporting bowel preparation using Boston Bowel Preparation Scale (BBPS) in clinical practice. METHODS The study was a prospective observational cohort study which enrolled subjects reporting for screening colonoscopy. All subjects received a gallon of polyethylene glycol as bowel preparation regimen. After colonoscopy the endoscopists determined quality of bowel preparation using BBPS. Segmental scores were combined to calculate composite BBPS. Site and size of the polyps detected was recorded. Pathology reports were reviewed to determine advanced adenoma detection rates (AADR). Segmental AADRs were calculated and categorized based on the segmental BBPS to determine the differential impact of bowel prep on AADR. RESULTS Three hundred and sixty subjects were enrolled in the study with a mean age of 59.2 years, 36.3% males and 63.8% females. Four subjects with incomplete colonoscopy due BBPS of 0 in any segment were excluded. Based on composite BBPS subjects were divided into 3 groups; Group-0 (poor bowel prep, BBPS 0-3) n = 26 (7.3%), Group-1 (Suboptimal bowel prep, BBPS 4-6) n = 121 (34%) and Group-2 (Adequate bowel prep, BBPS 7-9) n = 209 (58.7%). AADR showed a linear trend through Group-1 to 3; with an AADR of 3.8%, 14.8% and 16.7% respectively. Also seen was a linear increasing trend in segmental AADR with improvement in segmental BBPS. There was statistical significant difference between AADR among Group 0 and 2 (3.8% vs 16.7%, P < 0.05), Group 1 and 2 (14.8% vs 16.7%, P < 0.05) and Group 0 and 1 (3.8% vs 14.8%, P < 0.05). χ(2) method was used to compute P value for determining statistical significance. CONCLUSION Segmental AADRs correlate with segmental BBPS. It is thus valuable to report segmental BBPS in colonoscopy reports in clinical practice.

New Developments in Mechanical Enhancement of Colonoscopy: Cuffs, Caps and Rings.

Background: Colorectal cancer (CRC) is a common cause of cancer-related deaths. Early detection of precursor lesions in the adenoma-carcinoma sequence via colonoscopy can decrease mortality from CRC. Summary: In this review article, we have summarized retrospective studies, prospective single center, multicenter studies and randomized controlled trials describing the efficacy of endocuff colonoscopy (EC), cap-assisted colonoscopy (CAC) and endorings colonoscopy (ERC). Indications, techniques, outcomes, limitations and complications reported are discussed. Key Message: Use of colonoscope with cap, cuff or rings attached to its distal tip has been shown to increase the polyp detection rate and adenoma detection rate, predominantly for the small polyps (<1 cm) and proximal colon location. Evidence is uniform for EC and ERC but not for CAC. Benefits of shorter cecum intubation time, improved cecum intubation rates and decreased pain scores during colonoscopy done with assistance of cuff or cap has potential to decrease the number of incomplete colonoscopy and increase overall patient satisfaction, thus improving follow-up. In the absence of any additional adverse events, EC, CAC and ERC have potential to enhance the benefits of colonoscopy.